Gastroenterology 2021;161:e22–e33

Table 1.TG-18 criteria compared to ERCP diagnosis of acute

Abstracts from the Advancing cholangitis (p<0.05)

Clinical Practice: GI Fellow-Directed ERCP

diagnosis
ERCP
diagnosis
Quality Improvement Projects of acute
cholangitis
of acute
cholangitis
Session at DDWÒ Yes (n¼72) No (n¼19)
TG-18 criteria Diagnostic 62 (86%) 7 (37%)
Use of Tokyo Guidelines (TG-18) for Acute Cholangitis
Provides Improved Specificity and Accuracy Compared to TG-18 criteria Not diagnostic 10 (14%) 12 (63%)
Fellow Clinical Assessment: A US Academic Center Pilot Study
Ahmad Alkaddour,1 Amit Hudgi,2
Anabel Liyen Cartelle,3 Amr Ahmed,2 Carlos Palacio,4 Table 2.Comparison of fellow clinical assessment to
Kenneth Vega,1 John Erikson Yap1 confirmed diagnosis of acute cholangitis (p>0.05)
1
Department of Gastroenterology, Augusta University ERCP ERCP
Medical Center, Augusta, Georgia; 2Department of Internal diagnosis diagnosis
Medicine, Augusta University Medical Center, Augusta, GA; of acute of acute
3
Medical College of Georgia, Augusta, Georgia; and cholangitis cholangitis
4
Department of Internal Medicine, University of Florida
College of Medicine-Jacksonville, Jacksonville, Florida Yes (n¼72) No (n¼19)
Fellow Clinical Assessment 65 (90%) 19 (100%)
BACKGROUND AND AIM: Acute cholangitis is a serious medical
problem unless treated early. Although the diagnostic grading Fellow Clinical Assessment 7 (10%) 0 (0%)
criteria on the 2018 Tokyo Guidelines (TG18) are used
worldwide as the primary standard for management of acute
cholangitis (AC), they need to be validated through imple- Conflicts of interest
mentation and assessment in actual clinical practice (2). Our The authors disclose no conflicts.
study aims to apply and compare if the Tokyo 2018 guide-
lines can improve diagnostic accuracy and assist in earlier
detection of acute cholangitis in an academic center in the A Quality Improvement Project to Improve Knowledge of
United States. This is the first of its kind of study in the United the Cost of Single-Use Endoscopy Devices in a University-
States to our knowledge. METHODS: A retrospective review of Based Endoscopy Center
206 charts with the International classification of disease-9 Cary C. Cotton Lisa M. Gangarosa
(ICD-9) code “cholangitis” and/or ICD-10 codes “acute chol- BACKGROUND: Single use endoscopy devices comprise a sig-
angitis, other cholangitis, and calculus of bile duct with nificant burden of expense to endoscopy units and many de-
cholangitis” was made in an academic center. Inclusion vices are not separately chargeable. Quality improvement
criteria were anyone evaluated by a GI consult fellow in the projects in surgical settings have improved participants’
inpatient setting with a suspected diagnosis of acute chol- knowledge of the cost of surgical tools and subsequently
angitis. Of these, 91 met inclusion criteria and were included reduced expenditures, but no such projects have been
in the analysis. TG18 criteria administered and chi-square described in the case of single-use endoscopy devices. METH-
analysis was done on a 2 by 2 cross-tabulation. RESULTS: Of ODS: We performed a quality improvement project with the
those diagnosed with cholangitis, 86.1% were diagnostically plan-do-study-act framework to assess and improve partici-
positive based on TG18 criteria (sensitivity). Those without pants’ knowledge of the cost of single-use endoscopy devices.
cholangitis were non-diagnostic on TG18 63.2% of the time We assessed baseline knowledge of the cost of 20 different
(specificity). Accuracy was estimated to be 81.3% (p<0.05) devices with a questionnaire. We then utilized two in-
(Figure 1). By contrast, fellow clinical suspicion suggested a terventions, an active intervention at one site and a passive
sensitivity of 90.3% and a specificity of 0%. Accuracy was intervention at 2 sites. At the active intervention site, endos-
estimated to be 71.4% which was statistically not significant. copy nurses called out the cost of each single-use endoscopy
CONCLUSION: Our results suggest that application of the TG18 device used in each case, while at the passive sites we displayed
criteria can reduce the rate of false positives and improve posters that listed the name, cost, and image of each devices.
diagnostic accuracy thus decreasing costs and avoiding un- The intervention was performed for 60 days, and then a follow-
necessary ERCPs with associated complications. up questionnaire was administered. We performed random
effects Poisson regression for pairwise comparisons of accu-
racy with 15% and 30% error thresholds. RESULTS: There
were 38 participants at baseline and 19 (50%) completed the
follow-up questionnaire and were included for analysis. The
COVID pandemic did delay the intervention phase resulting in
loss of some study participants due to relocation. Participants
were within 15% of the actual device cost for a mean 2.4
devices out of 20 at baseline and a mean 4.6 devices at
follow-up (p ¼ 0.01). Participants were within 30% of the
actual device cost for a mean 3.8 devices out of 20 at baseline
and a mean 6.1 devices at follow-up (p ¼ 0.04). This